Claim Form
For Lost or Damaged Parcels Fed-Ex International shipments

Instructions
1. File a tracer with the carrier without delay when a package is lost or notify the carrier immediately if the package is damaged.
2. After the carrier confirms that the shipment is lost or damaged, file your claim with the carrier.
3. When you receive payment from the carrier for its liability:
A. Complete and mail the CLAIM FORM within 60 days of the carrier’s payment.
B. Complete one U-PIC CLAIM FORM per claim.
C. With this form include the following pieces of information:
1) A copy of the carrier’s form, with the ‘LDI’ number, or other identifying claim number.
2) A copy of the carrier settlement check.
3) A copy of the original invoice to the consignee.
4) If claim is for damage, state if repairs are possible, the cost of repair and any salvage value if not repairable.
5) A copy of the carrier’s receipt/waybill unless shipped UPS or Federal Express.
6) Freight charges are only recoverable if the freight value is declared in the insured value.
D. If the claim is for damage, hold on to the damaged item until the claim is resolved as pictures may be requested.
4. Mail to:     U-PIC                                                               Fax to:  818-971-3325
       28001 Dorothy Dr., 2nd Floor         or
       Agoura Hills, CA 91301
5. If you have any questions, please call our office at 800-955-4623, option 4 for claims.

Claim Information


Company:        [_GSCM_]

 

 

Name:              [_______________________]
Address:          [_______________________]
Phone:             [_______________________]

 

Email:                [_______________]                                                  

 

Carrier:            [_______________________]

Invoice #:         [_______________]

Consignee:       [______________________]

Consignee Zip/Country:     [________________]

 

Ship Date:        [______________]

Tracking #:       [______________________]

Declared Value: [$_____________]

Claim is for: Loss: ___ Damage: ___ Shortage: ___     If Damaged is it repairable? Y / N

Description of Items:              ________________________________________________                                               

Description of Damage:         ________________________________________________

Amount of your claim  

Invoice Value:

$_________________

Total Claim Amount:

$_________________

Less Amount Recovered (if damaged):

$_________________

Less Amount Paid By Carrier:

$_________________

Balance To Be Paid By Underwriters:

$_________________

Claims checks should be mailed to the attention of:    _________________________________

Prompt settlement of your claim will be subject to the full completion of the above claims information and submittal of the required documents. Failure to comply will delay settlement.

Signature:    _____________________________________   Date:    __________________________
 
WARNING: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. (CC1871.2)